Studying the effect of education on women's pap-smear knowledge, attitudes, and behavior

doi:10.21203/rs.3.rs-5042648/v1

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Research Article

Studying the effect of education on women's pap-smear knowledge, attitudes, and behavior

https://doi.org/10.21203/rs.3.rs-5042648/v1

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Background

Prevention and early diagnosis are crucial factors in the treatment and control of cervical cancer. The present study investigates the relationship between demographic characteristics and the effect of education on the knowledge, attitude, and performance of women who were referred to Varamin health centers and underwent Pop-smear tests.

Methods

This descriptive-analytical study was conducted in 2021 on 311 women who were selected by a convenience sampling method. Data were collected from the samples from August 15, 2021, to March 15, 2021. First, the level of their knowledge, attitude, and performance was evaluated by a researcher-made questionnaire whose validity and reliability have been confirmed. Then, the women were given the necessary education regarding the Pop-smear test. After one, the questionnaire was given to them again. Data were analyzed using the Pearson correlation coefficient, ANOVA, and paired t-test.

Results

Based on the results of one-way analysis of variance, before the education, the level of knowledge and performance increased with increasing age. However, after education, with increasing age, the subjects’ level of knowledge decreased and their performance increased.

Conclusions

It is necessary to provide comprehensive education for women about the Pop-smear test. Educating young, illiterate, or low-educated women, women without financial resources, and unemployed women, women without children, single, or divorced women, and people without underlying diseases should be prioritized.

Popanicolaou Test

Pop-Smear

Cervical Cancer

Women's Health

Sexual Health Education

Currently, cervical cancer is one of the major concerns of the World Health Organization since it is the fourth most common cancer among women worldwide. About 570,000 cases of cervical cancer were reported in 2008, leading to the death of about 300,000 people [1]. Some of the factors involved in cervical cancer include smoking, having multiple sexual partners, low gestational age, having sex at a young age, not using contraceptives in sex, having sexually transmitted diseases, use of oral contraceptives, lack of observing personal hygiene, and human Papillomavirus [2, 3]. Among these factors, the human Papillomavirus is the most significant factor in causing cervical cancer, so almost all cases of infection can be related to the existence of this virus [2, 4, 5]. This virus has low-risk to high-risk strains. Low-risk strains can cause anogenital warts. However, high-risk strains can cause cervical infections, precancerous lesions, and cancer cells, and ultimately malignancy [4, 5].

Also, the infection (almost more than two years) resulting from this virus, which remains for a long time, can become a predisposing factor for the development of cervical cancer. Hence, prevention, diagnosis, and timely treatment are among the most effective ways to control this disease [5]. Several types of vaccinations against the Papillomavirus can be used to prevent it. In the best case, this vaccination can prevent cervical cancer by 90%. For this reason, quick and early diagnosis of the disease is crucial [6]. It is almost impossible to treat cervical cancer in the final stages. However, the occurrence of the invasive stage of this cancer can be prevented to a large extent since the pre-invasive stage of cervical cancer is long. Therefore, by using cytology screening programs, it is possible to detect the occurrence of this cancer in the early stages and treat it [7]. Pop-smear method is one of the diagnostic methods in this regard. After conducting studies on smears of guinea pigs and then repeating the same successful studies on the female genital tract in 1920, Popanicolaou found swabs stained with human vaginal secretions through a microscope and realized that is easy to distinguish healthy cells from malignant cells in the vagina and the cervix. This method later became known as the Pop-smear method. Thanks to its ease of use and proper performance, it is used universally in cervical cancer screening [4]. This method was so effective that the death rate due to cervical cancer decreased by 70% worldwide thanks to the use of Pop-smear [4, 5]. Despite the availability of screening programs and their favorable effectiveness, the rate of women referring to health centers for Pop-smear tests is not favorable [8, 9], so only 27.1% of Iranian women aged 18 years and older have received Pop-smear tests so far [9, 10]. In this regard, the studies by Marashi and Falahi (2021) revealed that the control rate of cervical cancer in Iran is far from the favorable level [11, 12].

Based on the results of various studies, some factors prevent the screening. Some of these factors include shyness, fear of being diagnosed with cancer, lack of knowledge about cancer and methods of prevention, screening, and treatment, not having enough information about how to get cancer, not having enough time or enough money, lack of trust in medical staff and diagnostic methods, the culture level of society and family, customs, religion, level of education, and geographic location [13]. Since educating people can improve knowledge, create a positive attitude, and improve performance to perform preventive behaviors, to increase the probability of using the Pop-smear diagnostic test, educational programs should be implemented to improve knowledge and attitudes of women in the area of Pop-smear test [8]. Based on the results of various studies, there is a direct association between demographic characteristics, level of knowledge, and attitude of people with Pop-smear tests. The results of a study by Makunen (2021) revealed that with the increase in education and age, knowledge increases, and improving knowledge can be effective on attitude. Also, people with negative attitudes have less knowledge to perform screening [13]. Given what was stated about the significance of the Pop-smear diagnostic test and the unfavorable performance of women despite the availability of this test, and the relationship between demographic characteristics and the effect of education on improving the level of knowledge, attitude, and performance, the present study investigates the relationship between education, knowledge, attitude, and performance of women referring to Varamin health centers to do Pop-smear test.

Study design

This present descriptive and analytical study was conducted in 2021. After obtaining the code of ethics from the Ethics Committee of Shahid Beheshti University of Medical Sciences in Iran with ethics code: IR.SBMU.RETECH.REC.1399.1027, the researcher referred to the health centers of Varamin City explained the objectives of the study to the officials of the centers, and obtained their consent. The statistical population of this study included all women aged 18 to 45 years referring to health centers in Varamin. First, using previous related studies, the number of samples was determined according to the following formula [14]. Considering a 10% error, the number of samples was increased to 340 people. A convenience sampling method was used.

$\:\text{n}=\frac{{\text{z}}_{\raisebox{1ex}{${\alpha\:}$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.}^{2}{{\sigma\:}}^{2}}{{\text{d}}^{2}}$ = 311

$\:{\sigma\:}=18\:\:\:\:\:\:\:\:{\alpha\:}=.05\:\:\:\:\:\:\:\:\:\:\:\text{z}=1.96\:\:\:\:\:\:\:\:$ d=2 n=311

The inclusion criteria of the study included women aged 18 to 25 referring to the health centers of Varamin City, being willing to participate in the study, and being literate. The exclusion criteria of the study included not completing the questionnaires, having cervical cancer, and being a member of medical staff such as physicians, nurses, etc. In this study, all the subjects were adults, and at the beginning of the questionnaire, the volunteers were asked to fill out the questionnaire form if they had informed consent.

Data collection

Using a related study [14] about the knowledge, attitude, and performance towards the Pop-smear test and consultation with professors, a researcher-made questionnaire including demographic characteristics (age, marital status, employment status, education level, number of children, history of Pop-smear, and history of previous underlying disease), level of awareness, attitude and performance to measure the level of knowledge, attitude, and performance of the clients in Varamin health centers. The English version of the knowledge, attitude and performance evaluation questionnaire was attached (See additional file 1). Accordingly, the checklist was provided to several professors of the Nursing Faculty of Shahid Beheshti University of Medical Sciences. After obtaining their opinions and making the necessary corrections, the modified questionnaire was again provided to them. The collection of information through the questionnaire started on September 21, 2021, and until Continued on March 16, 2022. After applying their opinions, the questionnaire was finally prepared. The face validity method was used to determine the scientific validity of the questionnaire. In examining the reliability of the tool using the test-retest method, the questionnaire was submitted to 30 people at a two-week interval. The reliability of the questionnaire questions using Cronbach's alpha method was obtained at 0.88%, indicating the power of the tool to conduct this research. All three sections of knowledge, attitude, and performance were scored as weak, medium, and good. The poor criterion was from 0 to 33 percent, the medium criterion was from 33 to 66 percent, and the good criterion was from 66 to 100 percent.

Before starting the study, a researcher-made questionnaire was given to the subjects to collect demographic information and to evaluate their level of knowledge, performance, and attitude toward Pop-smear. The electronic questionnaire was sent via Whats-App to the subjects who were able to read and fill out the questionnaire personally. To facilitate the conditions for illiterate and low-literate people, the questionnaire was read by the questioner and completed exactly according to the answers of these subjects. After completing each questionnaire for 20 minutes (20 minutes in a normal state and about 30 minutes for illiterate people who answered with the help of the researcher), they were collected. The first author has access to information to identify participants during or after data collection. In this study, the contents of educational developed by the Ministry of Health, Treatment, and Medical Education were used to develop the appropriate educational content under the supervision and approval of the relevant professors. In this educational content, the causes of cervical cancer, the principles of self-care, observing the principles to prevent cervical cancer, the timing of Pop-smear screening and the reasons for doing it and its significance, and the risk factors of being infected with the human Papillomavirus and cervical cancer were described.

Then, educational content was immediately sent to the subjects through cyberspace to enhance their knowledge about Pop-smear and its benefits. After educating the subjects with the educational content, 3 questions were asked randomly from them, while the researcher was following the educational content to confirm receiving of the education and its understanding. After one month of providing the educational content, the same questionnaire was completed again by the subjects, and their level of knowledge, attitude, and performance after receiving the education was measured. The questionnaire was completed in the second round, as in the first round, in two virtual ways: through an internet link and using the Google form questionnaire or through a phone call (to receive and record the information of illiterate and low-literate people). Moreover, in all cases where it was possible to prevent the spread of the Covid-19, information was received through phone calls and an electronic questionnaire.

Statistical Analysis

Descriptive statistics (relative frequency, mean, and standard deviation) and inferential statistics (paired t-test, one-way analysis of variance, and Pearson correlation coefficient) were used to analyze the data. The results were analyzed in SPSS-25 software. The significance level was considered less than 0.05.

In the present study, 311 people in the age range of 18 to 45 years participated. The spouses of 95.5% of the subjects were alive. About 81% of the subjects had less than a diploma and 8% were illiterate. Most subjects were housewives (92.9%) and had less than three children (74%). Out of 311 subjects, 296 had no history of underlying physical disease and 145 people had a history of Pop-smear test. None of the subjects had a history of participating in educational classes on how to perform a Pop-smear test. Among the subjects who had a history of Pop-smear test, 85 people had done this test to prevent cervical cancer according to their own diagnosis and the rest had done it based on the physician’s diagnosis or the recommendation of the medical staff.

The results of a one-way analysis of variance showed that the level of knowledge increased significantly with increasing age in the first round of completing the questionnaire (before education). However, in the second round of completing the questionnaire (after education), the level of knowledge decreased significantly with increasing age. Additionally, before and after education, married or spouse-deceased women had a significantly higher level of knowledge than divorced women. The present study also shows that with increasing the level of education and the number of children before education, the level of knowledge increased significantly. However, after education, there was no significant relationship between the level of education and the level of knowledge, or between the number of children and the level of knowledge.

Also, before education, employed people had a significantly higher level of knowledge. However, after the education, no significant relationship was found between the employment status and the level of knowledge. Also, it was found that before and after the education, the knowledge level of subjects who had a history of Pop-smear tests was significantly higher than that of subjects who did not have a history of Pop-smear tests. Before education, the level of knowledge of subjects who had a history of disease was significantly higher than that of subjects who had no history of disease. However, after education, the knowledge level of subjects who had a history of disease was significantly lower than that of subjects who had no history of disease. Before and after the education, a significant relationship was observed between the different reasons for doing a Pop-smear test and the level of knowledge (Table 1).

The results of a one-way analysis of variance revealed that there was no significant relationship between the mean score of age and attitude, or between marital status and attitude score before and after the education. Also, with increasing the education level, the mean attitude score increased significantly before the education. However, after education, no significant relationship between the education level and the mean score of attitude score. Before the education, no significant relationship was observed between the number of children and the mean score of attitude. After the education, as the number of children increased, the mean score of attitude increased significantly. It was also found that employed people had a significantly higher mean score of attitude before education. However, after education, no significant relationship was found between employment status and the mean score of attitude.

It was also found that there was no significant difference between the mean score of attitude in the subjects who had a history of Pop-smear test and that in the subjects who had no history of Pop-smear test before the education. However, after the education, a significant difference was found between the mean score of attitude in the subjects who had a history of doing the Pop-smear test and that in those who did not have a history of Pop-smear test. Before and after the education, no significant difference was observed between the mean score of attitude in subjects who had a history of disease and those who had no history of disease. Before and after the education, a significant relationship was observed between the different reasons for performing a Pop-smear test and the mean score of attitude (Table 1). The results of the one-way analysis of variance showed that the mean score of performance increased significantly with increasing age before and after education. Also, no significant relationship was found between marital status and the mean score of performance score before and after education. It was also found that the mean score of performance decreased significantly as the level of education increased before and after the education. However, after the education, no significant relationship was found between the level of education and the mean score of performance.

Additionally, before and after the education, no significant relationship was observed between the number of children and the mean score of performance. Also, before the education, employed subjects had a significantly higher mean score of performance. However, after the education, there was no significant relationship between the employment status and the mean score of performance. Before and after the education, no significant difference was observed between the mean score of performance in the subjects who had a history of Pop-smear tests and that in the subjects who did not have a history of Pop-smear tests. Before and after education, no significant difference was observed between the mean score of performance in the subjects who had a history of disease and that in the subjects who did not have a history of disease. Before and after the education, no significant relationship was found between the reason for performing the Pop-smear test and the mean score of performance (Table 1).

Table 1

Comparison of changes in the mean of underlying variables between the three variables of knowledge, attitude, and performance before and after education
Variable		Knowledge	Sig	Attitude (mean)	Sig	Performance (mean)	Sig
Age	Before	50.68	0.001	443.56	0.103	634.56	< 0.001
Age	After	14.71	0.055	170.81	0.306	1489.86	< 0.001
Marital status	Before	35.13	< 0.001	466.50	0.093	1.33	0.846
Marital status	After	17.59	0.031	26.41	0.833	96.53	0.199
Education	Before	141.07	< 0.001	1978.67	< 0.001	220.53	0.042
Education	After	10.90	0. 116	336.8	0.096	14.87	0.882
Number of children	Before	32.77	0.012	381.52	0.142	10.73	0.860
Number of children	After	0.435	0.918	1244.07	< 0.001	322.68	0.062
Job	Before	49.53	< 0.001	1167.70	0.002	156.14	0.035
Job	After	5.07	0.369	368.99	0.077	36.55	0.430
History of test	Before	1.56	< 0.001	8.37	0.536	7.55	0.307
History of test	After	0.62	0.033	7.58	< 0.001	10.84	0.110
History of disease	Before	0.33	0.047	-0.51	0.839	-1.54	0.051
History of disease	After	-0.69	0.026	-3.60	0.128	-0.69	0.086
Cause of performing test	Before	235.98	< 0.001	5398.21	< 0.001	48.24	0.506
Cause of performing test	After	52.62	< 0.001	4110.85	< 0.001	147.52	0.474

The results of the paired t-test revealed that the levels of knowledge, attitude, and performance increased significantly after the education compared to before the education (P = 0.000) (Table 2)

Table 2

Comparison of mean scores of knowledge, attitude, and performance before and after education
Variable	Before education		After education		sig
Variable	Mean	SD	Mean	SD	sig
Knowledge	3.54	1.92	4.95	1.59	0.000
Attitude	52.70	9.88	58.44	8.84	0.000
Performance	75.44	5.92	81.13	7.66	0.000

Regarding the age variable, the results showed that the level of knowledge and performance had a direct and significant relationship with increasing age before education. However, after education, the level of knowledge decreases with increasing age, and the level of performance increases. There was no significant difference between the mean scores of attitude in different ages before and after education. In this regard, the results of a study conducted by Al-Mubarak in Sudan (2016) revealed that most subjects who performed the Pop-smear test were over 30 years old [15]. Unlike the results of the present study, a study by Sheel Pakar (2020) in Nepal showed no significant relationship between age and level of knowledge. However, the mean score of attitude toward Pop-smear is higher in young people than in middle-aged people [16]. Tabeshian also showed that there is no significant relationship between knowledge and attitude toward performing Pop-smear tests before and after education. However, a significant direct relationship was found between performance and age before and after education [17]. Since learning is faster and more stable at younger ages and is associated with more challenges at older ages, the results of the present study highlight the significance of learning and improving knowledge in younger women and improving performance at any age. However, the difference between the results of the present study and those of a study by Sheel Pakar and Al-Mubarak may be due to the difference in the age range of the studied subjects and related cultural differences. Cultural and national differences can play a significant role in affecting the type of education (face-to-face, virtual, or combined) of people in different age groups.

Regarding the marital status in the present study, before and after education, married women and spouse-deceased women had a higher level of knowledge than divorced women. However, no significant relationship was observed between the mean scores of attitude and performance and marital status before and after education. In a study conducted by Miles in Peru (2021) regarding the Pop-smear test, results revealed that married women performed better than single women. According to Miles, lack of knowledge among single women is the reason for this result since most women believed this one must have at least one child to do a Pop-smear [18]. Although the study conducted by Motavali revealed the positive attitude of married women towards Pop-smear, the knowledge and performance levels of married women were very low [19]. Given what was stated, increasing knowledge in a scattered and inconsistent manner or simply having a positive attitude cannot be a definitive factor in improving performance, and knowledge should be provided to people sufficiently and fully.

The results of the present study about the contextual variable of the number of children indicated that there is only a significant relationship between the increase in the number of children and the increase in knowledge before education. However, after education, a relationship was found only between the increase in the number of children and the increase in attitude. These results are consistent with the results of a study conducted by Daher (2019) in Saudi Arabia, as it showed a significant relationship between the increase in the number of children and the increase in knowledge about the Pop-smear test [20]. Also, a study by Miles (2021) in Peru showed a significant direct relationship between increasing the number of children and increasing the levels of knowledge, attitude, and performance. It seems that mothers' motivation to take care of their child and themselves increases and their relationship with other mothers improves after the birth of a new child. These communications increase the information and motivation of mothers to receive health services. Also, the number of referrals to health centers and communication with the medical staff also increases. It increases women's knowledge about health issues [17, 18].

Based on the results of the present study about the relationship between the level of education and the variables of knowledge, attitude, and performance, the results revealed that with increasing the level of education before education, the level of knowledge and attitude increases, but the level of performance decreases. However, there was no significant relationship between the level of education and the mean scores of knowledge, attitude, and performance after education. The impact of education on a person's information is obvious so the lowest level of knowledge before education is seen among the illiterate group, indicating the need to prioritize the illiterate and less-educated groups. This result indicates the effectiveness of education in improving knowledge and attitude since after there is no significant difference between women’s different levels of education and their knowledge and attitude after the education. However, women with higher education had a higher level of knowledge and attitude before the education.

In this regard, we can refer to the results of a study by Besu (2014), which showed that women with higher education have a higher level of knowledge about cervical cancer [21], or a study by Daher, who stated that as the level of education increased, the mean score of knowledge and attitude toward performing Pop-smear and health care increased [20]. Unlike the results of the present study, Tabeshian reports that an increase in education does not necessarily lead to an increase in knowledge, because he found that the knowledge of subjects with a bachelor's degree was better than that of those with higher education [17]. Therefore, it can be concluded that an increase in the level of education may cause an increase in knowledge, but an increase in education cannot necessarily cause a definite increase in knowledge.

Attitude and performance of employed people were significantly higher than those of non-employed people before education. However, after education, a significant relationship was not found between the mean scores of knowledge, attitude, and performance of employed and unemployed women. However, before education, employed women had a higher level of knowledge and attitude than unemployed women. Consistent with the results of the present study, the study by Daher (2019) in Saudi Arabia revealed a relationship between women's knowledge and their employment, as it revealed that employed women more than unemployed women deal with healthcare issues such as the Pop-smear test [20]. In this regard, the results of a study by Shrestha (2022) in Nepal showed that many women worldwide are deprived of free access to Pop-smear tests. Hence, although a person has a favorable attitude and motivation to perform a Pop-smear, the high cost of the Pop-smear test is a significant barrier to doing it [22]. It can be stated that employed women have financial independence and can better afford their treatment and care expenses [22, 23]. Also, due to the higher communication of employed women with other members of society, they have better knowledge, attitude, and performance regarding Pop-smears. Hence, special attention should be paid to sexual health and care of unemployed women.

In the present study, the mean score of knowledge of subjects who had a history of Pop-smear tests before and after the education was higher than that of subjects who had no history of Pop-smear tests. However, more than half of the subjects who participated in the present study (53%) had never had a Pop-smear test before. Given the statistical population of this study, it can be stated that Varamin women do not care much about their sexual health. This result is consistent with the results of studies conducted by Zarei, Ghalavandi, and Mohebi. In a study by Zarei (2010), the results indicated that women who had done at least one Pop-smear test had more knowledge than women who had not done this test yet [24]. Also, the study by Ghalavandi (2021) showed that the mean knowledge score of women who had a history of Pop-smear tests was higher [8].

A study by Mohebi revealed that education and frequent visits of women to health centers and communicating with the medical staff increase women's knowledge level [25]. Improving women's knowledge leads to a more accurate understanding of the barriers to performing a Pop-smear test (shame, embarrassment, fear, etc.) and an increase in sensitivity to the necessity of doing this test. Thus, repeated education in every referral of women to these centers can be effective in improving their knowledge. The present study also showed no significant difference between the attitude and performance scores of women who had a history of Pop-smear tests and those of women who did not have this history before education. Although the mean attitude score of the subjects who had a history of Pop-smear tests was more than that in women who had a history of Pop-smear after education, no difference was observed in the performance of these two groups.

Based on the results of a study by Jalilian, gaining more knowledge in older women can induce the belief that everyone is immune to health risks and threats by knowing a set of information, so there is no need to adopt preventive behaviors. In other words, this belief describes a person's understanding and attitude, weakening the adoption of any preventive behavior [26]. In this regard, the results of a study by Tadse (2020) in Ethiopia and Al-Mubarak (2016) in Sudan showed that women do not consider it necessary to perform screening tests just because they think they are healthy [15, 27]. Based on the results of the present study, after providing correct and valid education and improving the necessary knowledge, the incorrect beliefs and attitudes will be corrected and will increase the mean score of attitudes in women.

Consistent with these results, a study by Asgharnia showed that the mean score of the attitude of people who had a history of Pop-smear test and had acquired appropriate information in this field was higher than that of people who had not done this test [28]. Despite the change in the mean attitude score after the education in the present study, it seems that the time required to change the performance of women in this study should be more than one month. The present study also showed a relationship between the history of underlying disease and women's knowledge, attitude, and performance. Before the education, the knowledge level of people who had a history of disease was significantly higher than that of people who had no history of disease. However, after education, the level of knowledge of people who had a history of disease was lower than that of people who had no history of disease. It indicates the significant effect of education on the level of knowledge of people. Additionally, before and after the education, no significant relationship was observed between the mean score of attitude and performance and the history of the disease.

Consistent with these results, two studies conducted in Nepal (2022) and Ethiopia (2020) showed that having an underlying disease, especially sexually transmitted diseases, in women increases referrals to health centers, leading to more communication with the medical staff and a higher level of knowledge [22, 29]. Therefore, there is limited knowledge about diseases and treatment in areas where access to health and treatment is poor [22]. Based on the results of the present study, providing education by the medical staff increased the mean scores of knowledge and attitude of women who have taken measures to prevent cervical cancer by self-diagnosis or had done a Pop-smear test. However, no significant relationship was observed between the reasons for doing the Pop-smear test and the mean score of performance.

In this regard, the results of a study by Shrestha revealed that one of the crucial factors in changing women's knowledge and attitudes toward Pop-smear tests can be the advice of physicians and medical staff of the same sex (female). Thus, the advice of physicians and medical staff can be effective in improving women's knowledge and changing their attitudes [22].In this regard, the results of the studies conducted by Tabeshian (2018) and Bahri (2015) showed that most participants had done a Pop-smear on the physician’s advice [17, 30]. Other studies have shown that although women obtained the necessary information via cyberspace and mass media, they did not have sufficient and correct knowledge about prevention methods or risk factors [15, 20]. It seems that obtaining information through cyberspace and mass media cannot increase the needed knowledge of women sufficiently. Hence, education should be provided by qualified people or systems such as the medical staff in the health centers. The analysis of the results confirms the effectiveness of education in virtual space on the variable of knowledge of women referring to the health center. Although education is one of the primary ways of transferring information to people to improve knowledge, the appropriateness of educational content and the educational method significantly affect the effectiveness of learning [31].

In this regard, a study by Baghani Moghadam (2018) showed that the knowledge of women who received sufficient education about performing Pop-smear tests increased compared to before. The education also improved the health model structures of perceived sensitivity, perceived severity, and perceived barriers, which significantly affect the person's learning about a health practice [32]. Also, a study by Parsa (2016) showed a significant increase in the mean knowledge of women about cervical cancer, its causative factors, and performing a Pop-smear test after group education [33]. Moreover, the studies by Tahmasabi and Pirzadeh showed that the knowledge of women who were trained based on the health belief model increased significantly [34, 35]. Group education and counseling are much more attractive than individual education [31]. Also, education based on the health belief model, which is one of the best models to encourage people to gain knowledge and improve learning, is much more effective than traditional methods. Thus, it seems that acquiring knowledge requires appropriate education since education must be satisfactory, reassuring, attractive, accurate, and adequate to have a significant impact on people's learning [32].

This study also revealed a significant improvement in the mean attitude score of the subjects after the education. The results of the present study are consistent with those of studies by Heydari-Sarvestani and Hanifi. The study by Heydari-Sarvestani (2016) in Fasa showed that the behavioral motivation of women increased significantly after a planned education program and their attitude toward Pop-smear test became more positive. Thus, the significance of planned education in changing positive attitudes is highlighted [9]. Additionally, a study by Hanifi revealed that the motivation and attitude toward Pop-smear tests of women who received education through lecture and group discussion improved significantly [36].

One of the significant ways to change the attitude of people is to talk about their opinions and brainstorm in this area. Stating opinions and observing other people's reactions are significant ways to change attitudes [36]. Although some studies have indicated the positive effect of education on attitude, a study by Farsi revealed that although education improved knowledge of the subjects, it did not significantly affect their attitudes. Farsi stated that the short time of the study is the reason for not improving the attitude of the subjects. The lack of sufficient education, a negative attitude toward the examination, cultural problems, misunderstanding of the disease, and many psychosocial factors can affect the attitude of people and education alone is not enough to improve the attitude in society [37]. The present study also showed an improvement in the mean performance score of women after the education compared to before the education. In other words, women's performance regarding the follow-up of health care related to sexually transmitted diseases and the use of Pop-smear tests increased, meaning that women had been referred more for Pop-smear tests than before the education.

The result of the present study is consistent with those of other studies by Baghiani Moghadam, Parsa, and Heydari Sarvestani. In the study by Baghani Moghadam, women's knowledge about sexual health care and the significance and method of doing Pop-smear tests increased and it ultimately caused a significant increase in women's performance. Education caused an almost five-fold increase in the rate of performing Pop-smear tests. Before the education, only 12.6% of women had performed a Pop-smear. However, after the education, it increased to 63.8% [32]. Similar results were reported in the study by Parsa. In the study by Parsa, rural women received group education and counseling and their performance regarding Pop-smear tests increased significantly. There were many barriers to women doing Pop-smear tests. These barriers included the fear of doing Pop-smear tests, the cost of commuting, lack of knowledge, insignificance, embarrassment, and misbehavior of health staff. Despite these barriers, education showed significant and positive impacts on their performance [33].

In the study by Heydari Sarvestani, planned education increased knowledge, changed attitudes, and ultimately increased performance and improved behavior regarding the Pop-smear test. This study indicated the direct effect of the planned educational method, highlighting the efficiency of this type of educational method [9]. Despite the effect of education on improving women's performance in Pop-smear, as reported in different studies, the results of the present study are not consistent with the results of a study by Tabeshian (2009) in Isfahan. Although the mean score of knowledge and attitude increased significantly after the education in the study by Tabeshian, no difference was observed before and after the education regarding the mean performance score of the subjects [17].

In this regard, we can refer to the statistical population in the study by Tabeshian since it included only people with a university education. Tabeshian stated that female teachers did not have enough time to do Pop-smear tests due to the lack of time and high workload. However, it is debatable that people with a bachelor's degree have done Pop-smear tests more than people with a master's degree. Additionally, people with older age had better performance. Tabeshian explained it in this way that people who are near the end of reproductive age are more concerned about sexual health and fertility [17]. Generally, the lack of sufficient knowledge or the combination of knowledge with an inappropriate attitude are some of the barriers affecting performance and behavior change, in addition to the appropriate period for a change in performance. Thus, particular attention should be paid to the education method to create a positive attitude and knowledge since appropriate knowledge and the right attitude can create more effective changes in behavior and performance [32]. Given what was stated, it can be concluded that providing proper education based on correct and sufficient scientific materials with attractive methods can cause positive changes in attitude, and thus, cause significant improvement in people's performance.

Limitations

The limitation of the present study was to ensure that people read the educational content provided by them. In this regard, we tried to ensure this issue as much as possible by asking three questions about the educational content.

Based on the results of the present study, it is necessary to develop a comprehensive program for the education of women in society. In this regard, more emphasis should be placed on young women, illiterate or low-educated women, and unemployed women without financial resources, women without children, single or divorced women, and healthy people without underlying diseases. Moreover, since there is no well-developed planning for educating the benefits and necessity of performing Pop-smear tests by the Ministry of Health or Education, it is highly recommended to develop and present appropriate educational programs for the policymakers. However, since none of the studied data were single women and only 1 person out of 311 was divorced, it is recommended to conduct more studies on these two groups.

Ethics approval and consent to participate

This study is related to the project NO.4343 from Student Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran (IR.SBMU.RETECH.REC.1399.1027). Written informed consent to participate in the study was obtained from all participants. The present manuscript is ethically in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data

The data presented in this study are available upon request from the corresponding author.

Competing interests

Nil.

Funding

This study was supported by Shahid Beheshti University of Medical Sciences. The funder has only sponsored. The funder had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Author contributions

FR and AKM contributed to conceptualization of the study, methodology, data collection, data analysis, data interpretation and original draft preparation. RRN and HA contributed to conceptualization of the study, methodology, data interpretation and validation, and the original draft revision and edit. SHA contributed to validation and the original draft revision and edit. SA contributed to data analysis, data interpretation and validation. All authors have read and agreed to the final version of the manuscript.

Acknowledgement

We also appreciate the “Student Research Committee” and “Research & Technology Chancellor” in Shahid Beheshti University of Medical Sciences for their financial support of this study.

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Studying the effect of education on women's pap-smear knowledge, attitudes, and behavior

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Background

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